TRSUT LOGO. Directorate Lead Clinical Lead Finance Lead Business Development Manager Date Submitted 15 th March 2010

Transcription

1 TRSUT LOGO Directorate Medicine (Respiratory) Service Proposal Service Airways Clinic Directorate Lead Clinical Lead Finance Lead Business Development Manager Date Submitted 15 th March 2010 Directorate/Support Service Impact Checklist Directorate Person Consulted Impacted Anaesthetics / Theatres No N/A Child Services No N/A Emergency Department No N/A General Medicine Head & Neck No N/A Neurosciences No N/A Oncology No N/A Orthopaedics No N/A Plastic Surgery No N/A Renal No N/A Women s Services No N/A Pathology No Imaging Professional Support Services Pharmacy No Estates & Facilities No IT Services Information Services No N/A Pastoral Care No N/A Human Resources As part of implementation Laundry No N/A Medical Staffing No N/A Finance Workforce Directorate Call Centre Medical Records Waiting Lists No N/A Equality & Diversity N/a See assessment Patient / Public Involvement N/a - Sign Off 1. Introduction to Service Proposal 1.1 The purpose of this paper is to provide an overview and options appraisal, given the current knowledge of the airways services. This is to deliver a multi-disciplinary (MDT) approach for the management of Vocal Cord Dysfunction (VCD) and other associated conditions. 1.2 VCD is a complex respiratory disorder, which is often wrongly diagnosed as asthma or other respiratory disease. Making the correct diagnosis is vital to prevent unnecessary intensification of medical treatment. Appropriate intervention for VCD is often associated with a subsequent reduction in asthma medication and for chronic patient s reduced hospital admissions and length of stay. 1.3 The Trust receives a high number of Tertiary referrals into the service, this is due to its specialist remit. The Trust will not be affected by reduced hospital admissions as many of our patients come from out of region. At the moment our Primary Care Trust (PCT) patients make up 60% of SLT referrals and 40% are from outside of the area. The Trust has seen an increase in out of area referrals and the referrals are increasing rapidly, yet our referral rates are much the same (see graph in appendix 2). Page 1 of 12

2 1.4 Over the previous year the respiratory service has met waiting times through the consistent use of waiting list initiatives (WLI s). This has been caused by a shortfall in baseline capacity in the speciality to meet new and follow up appointments. 1.5 The respiratory service has seen greater demand in particular on follow up clinics being created through WLI s. 1.6 Moving forward it is proposed to eradicate WLI from the three consultants that deliver the specialised service making a saving, and replace these with an asthma and ventilation nurse. This offers a more cost efficient delivery of service, and allows the right professional to see the patients at the right time. This will enable the nurses to see the patients that require more frequent appointments, therefore delivering a more quality service to patients and avoiding patients from being admitted into hospital. 2. Executive Summary This paper is set out in four sections:- Section 1 Expansion of the current speech and language therapy (SLT) role Section 2 Expansion of physiotherapy and psychology roles Section 3 The creation of a post for an asthma nurse Section 4 The creation of a post for a ventilation nurse The intention is to implement these roles into the team, and income generate via a MDT working approach. Through these posts the service will improve quality standards for outpatient and inpatient care and move the Trust one step closer to being recognised as the regional respiratory service. 3. Financial Implications The service currently brings in income of 81,691. If the proposal is implemented the service will bring in total income of 627,488 with recurrent costs year on year of 336,638 and a one off set up cost of 40,000 for equipment. The service will no longer need to continue to carry out WLI s therefore making a saving of 35,000. The service will bring in year on year after recurring costs 244,159. A full breakdown of the finances can be found in the appendix 1 4. Recommendations Options for Consideration 4.1 The Operational Management Team is asked to note the content of the paper Option 1 - To do nothing thus waiting lists will continue to build and the Trust will be at risk regarding 18 week breaches in this area, and the service will cease to develop. Option 2 - To support the proposed new service model by implementing the proposal, and delivering a higher quality and more efficient service to the patients 5. Background & Current Pathway 5.1 XXX complex asthma and undiagnosed breathlessness clinic is recognised as a leading and innovative site in the country for VCD diagnosis and management 1. The unit receives regional and national referrals and is now established as a leading centre for VCD management, which supports the development of the regional respiratory service. 1 Haines J, the Airways Clinic: A new multidisciplinary service for patients with vocal cord dysfunction. RCSLT Scientific Conference 2009 Partners in progress: spreading the word. Page 2 of 12

3 The optimal pathway for VCD management is pivotal on MDT care. The current pathway reflects this: NEW - Vocal Cord Dysfunction (VCD) Pathway Asthma Pathway Referral - (primary/ tertiary/consultant) MDT new respiratory SLT Bronchoscopy (bootlace) No VCD/mixed disease Referral - (primary/ New F/U therapy SLT New/F/U? Not asthma /mixed disease Multiple F/U Nasendoscopy Discharge SLT F/U (Average x 5 per patient) Nasendocopy (therapeutic) MDT F/U review appointment 6. Proposed Service Model Section 1 Expand the Speech and Language Therapy role (Job plan in Appendix 2) SLT 6.1 Current literature identifies SLT (within a MDT treatment forum) as the cornerstone for management. Bronchoscopy/nasendoscopy is the gold standard for diagnosis and treatment outcome review. Following diagnosis patients attend for outpatient SLT to gain airway control (average of 4 F/U clinic visits). A patient will receive approximately 1bronchoscopy & 2 nasendoscopy procedures throughout their pathway. 6.2 Current capacity - Since the clinic s conception in April 2006 referrals have increased at an average yearly rate of 58%. Demand now exceeds current SLT provision of 0.4WTE and 18 week wait target breeches are imminent. At present the SLT post is 0.4WTE, this allows for one diagnostic nasendoscopy session a week. 6.3 Currently those with VCD are unable to access review nasendoscopy slots during and after SLT intervention, this is due to the scarcity of slots. This is clinically suboptimal for the patient and a revenue opportunity lost for the Trust. There is also a need to increase out patient therapy clinics to improve quality of care and allow timely and effective delivery of a VCD therapy block. If referrals continue to increase at the average yearly rate (please see table in appendix 2) additional resource of 0.6WTE SLT will be required to meet this and ensure 18 week compliance. 6.4 The SLT post currently delivers 102 New and 204 F/U with 40 nasendoscopy. This brings in income into the directorate of 60,372 per year. Section 2 Expansion of the Physiotherapy and Psychology roles (Job plan in Appendix3) Page 3 of 12

4 Physiotherapy 6.5 There is a need to increase the physiotherapist and psychologist time to support the previously identified MDT approach. These posts would work alongside the expanded SLT post and offer support to patients through the pathway. 6.6 Physiotherapy sees patients with VCD who also suffer secondary hyperventilation and dysfunctional breathing patterns. Current capacity - The service at present is allocated a session a week of a physiotherapist s time, but this is in a mixed clinic. Currently, the physiotherapist will see and treat patients with bronchiectasis and other respiratory problems during this clinic. The referral rate for VCD patients to physiotherapy has risen by approximately 50% in the last year, which reflects the increased SLT referral figures (please see appendix 2). 6.7 Projected demand Designated protected time to treat VCD is essential to ensure optimal treatment within the MDT forum and prevent the 18 week waiting target from being breeched. 0.5 WTE of a physiotherapist will ensure projected demand is met and targets are achievable. Designated time also supports the development of the Lancashire Chest Clinic as a specialist respiratory centre. Psychology 6.8 Patients referred into psychology services often have a complex psychological history which manifests itself as VCD. Patients in this group may have suffered past trauma which requires a highly specialist mental health psychologist to manage effectively. Current capacity VCD patients are currently seen as part of the general medicine clinical psychology service. Currently psychology will see and treat patients in their general caseload and no specialist mental health support is in place. 6.9 Projected demand - Due to the complexity of these patients, a significant period of psychological intervention may be required, and as such a mental health psychologist will be needed to ensure ready access and appropriate follow up capacity. 0.5WTE of a psychologist designated time for the VCD service will ensure demand is met and targets are achievable. Designated time also supports the development of the Lancashire Chest Clinic as a specialist respiratory centre Section 3-4 Creation of a post - Asthma Nurse & Ventilation Nurse To support the delivery of the complex asthma and undiagnosed breathlessness clinic as well as support the development of the Lancashire Chest Centre. Two specialist respiratory nurses one at band 8a and the other post band 7 will work as part of the respiratory department supporting our tertiary complex asthma and Ventilation services. There will be specialist and general respiratory clinics run by the nurses They will also have an acute role improving inpatient care (allowing the trust to attain quality care benchmarks) and supporting early discharge. The implementation of the two nursing roles will enhance the service and give the patients a more quality service, by allowing the patients to be followed up on a more regular basis by the specialist nurses. These roles will support the follow up lists presently being done by the consultants, therefore allowing the consultants to see more new patients. Acute remit 6.12 The two specialist nurses would assess and support the management of all respiratory patients admitted on non-respiratory medical wards. They would ensure complex cases which had been reviewed by the respiratory medical team via consultant to consultant referrals had their management plans followed to ensure quality of care was received by the patients. All uncomplicated patients who are admitted to nonrespiratory wards they would ensure appropriate care was delivered and patients were efficiently discharged thus reducing length of stay (LOS) It has been proven by the homecare chronic obstructive pulmonary disease (C) team that LOS for inpatients in the Trust can be dramatically reduced by such specialist nurses. This new service will allow all patients admitted with respiratory illness to have a specialist review compared to around 45% of current patients. The band 8a nurse will also have the remit to work along side Intensive Care Unit (ICU) to support complex wean patients thus improving quality of care of these patients and reducing blocking of ICU beds and ventilators. Elective remit Page 4 of 12

5 6.14 Both nurses would run respiratory clinics. They each would have a specialist remit of complex asthma and ventilation. This service will help provide multidisciplinary service, which currently does not exist. General respiratory patients reviewed on the non-respiratory medical wards would be seen as emergency first in the nurse s general respiratory outpatient clinics This new service infrastructure will income generate, and support 18 weeks target attainment and improve quality of care in the out-patient setting of our specialist regional service. It will also decrease the need for the number of waiting list initiatives (WLI) clinics currently undertaken by the department. 7. Equality & Diversity 7.1 The service is open to all groups requiring a referral respiratory support. This service meets with Trust requirements regarding equality and diversity. A full assessment can be found in appendix Evaluation 8.1 In line with the agreed business development process a review of the case will be conducted approximately six months after implementation. This review will include all key stakeholders and will be presented back to OMT/CRG. 8.2 This will include a review of the actual demand on the service in 2009/10 and any further adjustments required. This review will incorporate activity and efficiency measure in line with the business development process. 8.3 In summary the proposal will provide additional income to the Trust, whilst providing a specialist quality developing service to the patients, with an MDT approach. Lead Officer - Clinical Lead - Business Development Manager Page 5 of 12

6 Appendix 1 INCOME NEW ACTIVITY - 10/11 ROADTEST TARIFF With Nasendoscopy as Daycase/Elective Current Activity New Additional Activity HRG Code HRG 4 Tariff Current Income Additional Income Total Income Speech & Language Therapy (SLT) Outpatients, New Outpatients, Follow Up Respiratory OPFA Multi Professional ,130 44,684 71,814 Respiratory OPFU Multi Professional ,446 45,206 72,652 Procedures Nasendoscopy Combined Daycase/Elective CZ06Q: Minor Throat Procedures without CC , , ,921 Bronchoscopy Combined Daycase/Elective DZ07Z: Fibre optic Bronchoscopy ,025 73,025 Asthma Outpatients, New 0 80 Outpatients, Follow Up Ventilation Outpatients, New 0 80 Outpatients, Follow Up Respiratory OPFA Single Professional ,043 19,043 Respiratory OPFU Single Professional ,106 86,106 Respiratory OPFA Single Professional ,043 19,043 Respiratory OPFU Single Professional ,885 68,885 Page 6 of 12

7 Total 346 2,524 81, , ,488 EXPENDITURE Resource Requirement WTE/Number Cost per test / staff cost Recurrent cost p.a. PAY Consultant ,000 26,800 Band 7 (Asthma Nurse) ,000 41,000 Band 8a (Ventilation Nurse) ,000 51,000 Band 3 HCSW (bronchoscopy clinics) ,000 20,000 Band 3 Clerical support ,000 20,000 Band 7 Physiotherapist ,000 20,500 Band 8a Specialist Mental Health Psychologist ,000 25,500 Band 8A SLT Nurse ,000 30,600 Band 7 SLT Nurse (for development) ,000 16,400 Band 1 medical records ,000 16,000 Clinic costs 39,522 SUB TOTAL: PAY ,322 NON PAY Clinic letters 2, Non pay (uniform/ travel/ training) 2,000 Course Fees 4,000 Clinic non pay incl SSD sterilisation ,000 Bootlace Bronchoscopes 2 12,000 1,000 Instrumentation fibrescope 500 Office Set up Removals/ Advertising Page 7 of 12

8 SUB TOTAL: NON PAY 29,316 Total Non Pay 336,638 SURPLUS 209,159 Saving on Waiting List Expenditure 35,000 SURPLUS INCLUDING WLI SAVING 244,159 Page 8 of 12

9 Appendix 2 SLT Projected Demand & Capacity Yearly SLT capacity Throughput at 1WTE Linear Referrals To SLT April 06-March 07 April 07-March 08 April 08- March 09 April 09-March 10 April 10-March 11 April 11- March 12 Physiotherapy referrals for VCD Linear Referrals To Physiotherapy April 06-March 07 April 07-March 08 April 08- March 09 April 09-March 10 April 10-March 11 April 11- March 12 Psychology referrals for VCD Linear Referrals To Psychology April 06-March 07 April 07-March 08 April 08- March 09 April 09-March 10 April 10-March 11 April 11- March 12 Page 9 of 12

10 Appendix 3 - Job Plan - Section 1 Principal Speech & Language Therapist Wk 1 Monday Tuesday Wednesday Thursday Friday Admin Research & Development Job Plan - Section 2 Acute MAU New F/U Senior Specialist Physiotherapist Wk 1 New F/U nasendoscopy Diagnostics nasendoscopy therapeutic Admin New & F/U Research & Development Monday Tuesday Wednesday Thursday Friday New New Follow up Follow up Admin Research/Audit/PDP New Follow up LTH Principal Psychologist Wk 1 Job Plan - Section 3 Monday Tuesday Wednesday Thursday Friday 1 New 1 New 2 Follow up 2 Follow up Research/Audit/PDP 1 New Admin 2 Follow up Specialist Asthma Nurse Wk 1 Monday Tuesday Wednesday Thursday Friday Acute ward Acute ward Acute ward assessment assessment assessment General Respiratory F/U & urgent F/U Acute ward assessment Job Plan - Section 4 Specialist Ventilation Nurse Asthma Nurse lead clinic F/U & urgent F/U Asthma Parallel clinic New & 4 F/U Feed back on patients to medical team & admin Research/Audit /PDP Admin Wk 1 Monday Tuesday Wednesday Thursday Friday Research/Audit Acute ward Ventilation General resp /PDP assessment parallel clinic F/U Acute ward assessment & ICU Admin Acute ward assessment & ICU & ICU Ventilation clinic nurse lead F/U New & F/U Feedback on patients & admin Acute ward assessment Page 10 of 12

11 Appendix 4 Equality & Diversity Impact Assessment 1 Referral or Access Criteria (Direct Discrimination) 1.1 Who will decide who is referred to this service? Referral into the service will be follow normal protocols and pathways. 1.2 For each of the following categories, please indicate to whom the service is open: DIRECT DISCRIMINATION TACKLING HEALTH INEQUALITIES CATEGORY TO WHOM IS THE SERVICE OPEN? DO THESE ACCESS CRITERIA INDICATE DIRECT DISCRIMINATION? FOR ANY IDENTIFIED DIRECT DISCRIMINATION PLEASE INDICATE PROPOSED AMENDMENTS AND/OR JUSTIFICATION FOR EACH CATEGORY, IS THERE A PARTICULAR TARGET AUDIENCE? WHY? AGE RANGE All No applicable No N/a N/a thresholds GENDER All. No applicable thresholds LEARNING All. No applicable DISABILITY thresholds MENTAL All. No applicable HEALTH thresholds SENSORY All. No applicable IMPAIRMENT thresholds PHYSICAL All. No applicable DISABILITY thresholds RACE All Races ETHNICITY All Ethnic groups CULTURE/ All cultures and CULTURAL TRADITIONS cultural backgrounds No exclusions RELIGION/ SPIRITUAL BELIEFS All religions SEXUAL ORIENTATION All OTHER N/a 2 The Enabling World (indirect discrimination) 2.1 Please indicate what measures or facilities, if any, are proposed for the service to support potential users in each of the following diversity and equality categories who may experience practical difficulties while using the service: CATEGORY AGE GENDER LEARNING DISABILITY PROPOSED ENABLING MEASURES None proposed None proposed TP-84 (Policy for the Care of People with Learning Disabilities) will apply where applicable. PLEASE EXPLAIN THE JUSTIFICATION FOR ANY GAPS Page 11 of 12

12 MENTAL HEALTH SENSORY IMPAIRMENT PHYSICAL DISABILITY RACE ETHNICITY CULTURE/ CULTURAL TRADITIONS RELIGION/ SPIRITUAL BELIEFS SEXUAL ORIENTATION OTHER Existing policies and toolkits will be applicable for this service Patients with visual impairments will be offered more extensive verbal discussions and information supply to ensure understanding None proposed. All areas involved in the delivery of patient services are wheelchair accessible. None proposed None proposed None proposed None proposed None proposed. Page 12 of 12